BUSINESS INCOME REPORT/WORK SHEET - BSR Insurance
POLICY NUMBER:
COMMERCIAL PROPERTY CP 15 15 06 95
BUSINESS INCOME REPORT/WORK SHEET
Your Name Location
Date
This work sheet must be completed on an accrual basis. The beginning and ending inventories in all calculations should be based on the same valuation method.
APPLICABLE WHEN THE AGREED VALUE COVERAGE OPTION APPLIES:
I certify that this is a true and correct report of values as required under this policy for the periods indicated and
that the Agreed Value for the period of coverage is $
, based on a Co-insurance
percentage of
%.
Signature Official Title
APPLICABLE WHEN THE PREMIUM ADJUSTMENT FORM APPLIES: I certify that this is a true and correct report of values as required under this policy for the 12 months ended
Signature Official Title Agent or Broker Mailing Address
CP 15 15 06 95
Copyright, ISO Commercial Risk Services, Inc., 1994
Page 1 of 5 o
BUSINESS INCOME REPORT/WORK SHEET FINANCIAL ANALYSIS
12 Month Period Ending
Income and Expenses
NonManufacturing Manufacturing
A. Gross Sales.................................... $
$
B. DEDUCT: Finished Stock Inventory (at sales value) at Beginning................ -
XXXXXXXX XXXXXXXX
C. ADD: Finished Stock Inventory (at sales value) at End......................... +
XXXXXXXX
D. Gross Sales Value of Production...................................... $
E. DEDUCT: Prepaid Freight ? Outgoing........ - Returns & Allowances................ - Discounts.................................. - Bad Debts................................. - Collection Expenses.................. -
XXXXXXXX
- - - - -
F. Net Sales........................................
$
Net Sales Value of Production........ $
G. ADD: Other Earnings from
your business operations (not
investment income or rents
from other properties):
Commissions or Rents
+
+
Cash Discounts
Received............................... +
+
Other......................................... +
+
H. Total Revenues.............................. $
$
Estimated for 12 Month Period Beginning
NonManufacturing Manufacturing
$
$
-
XXXXXXXX
XXXXXXXX
+
XXXXXXXX
$
XXXXXXXX
-
-
-
-
-
-
-
-
-
-
$ $
+
+
+
+
+
+
$
$
Page 2 of 5
Copyright, ISO Commercial Risk Services, Inc., 1994
CP 15 15 06 95 o
12 Month Period Ending
Income and Expenses
NonManufacturing Manufacturing
Total Revenues (Line H. from
previous page)................................ $
$
Estimated for 12 Month Period Beginning
NonManufacturing Manufacturing
$
$
I. DEDUCT: Cost of goods sold (see next page for instructions)...................... -
Cost of services purchased from outsiders (not your employees) to resell, that do not continue under contract............. -
Power, heat and refrigeration expenses that do not continue under contract (if CP 15 11 is attached)........................................ -
All ordinary payroll expenses or the amount of payroll expense excluded (if CP 15 10 is attached)..................................... -
Special deductions for mining properties (see next page for instructions)............................... -
J.1. Business Income exposure for 12 months....................................... $
-
-
-
-
XXXXXXXX -
-
-
-
-
- -
XXXXXXXX - -
J.2. Combined (firms engaged in
manufacturing & non-
manufacturing operations)..............
$
$
The figures in J.1. or J.2. represent 100% of your actual and estimated Business Income exposure for 12 months.
K. Additional Expenses:
1. Extra Expenses ? form CP 00 30 only (expenses incurred to avoid or minimize suspension of business & to continue operations)..................
2. Extended Business Income and Extended Period of Indemnity ? form CP 00 30 or CP 00 32 (loss of Business Income following resumption of operations, up to 30 days or the no. of days selected under Extended Period of Indemnity option).......................
3. Combined (all amounts in K.1. and K.2.)...................................
$
$
+
+
$
CP 15 15 06 95
Copyright, ISO Commercial Risk Services, Inc., 1994
Page 3 of 5 o
L. Total of J. and K. ......................................................................................................
"Estimated" column $
The figure in L. represents 100% of your estimated Business Income exposure for 12 months, and additional expenses. Using this figure as information, determine the approximate amount of insurance needed based on your evaluation of the number of months needed (may exceed 12 months) to replace your property, resume operations and restore the business to the condition that would have existed if no property damage had occurred.
Refer to the agent or Company for information on available Coinsurance levels and indemnity options. The Limit of Insurance you select will be shown in the Declarations of the policy.
Supplementary Information
12 Month Period Ending
NonManufacturing Manufacturing
CALCULATION OF COST OF GOODS SOLD
Inventory at beginning of year (Including raw material and stock in process, but not finished stock, for manufacturing risks)............... $
Add: The following purchase costs: Cost of raw stock (including transportation charges).......................... +
Cost of factory supplies consumed.............................................. +
Cost of merchandise sold including transportation charges (for manufacturing risks, means cost of merchandise sold but not manufactured by you)...................... +
Cost of other supplies consumed (including transportation charges).......... +
Cost of goods available for sale............. $
Deduct: Inventory at end of year (Including raw material and stock in process, but not finished stock, for manufacturing risks)............... -
Cost of Goods Sold (Enter this figure in Item I. on previous page).......... $
$ XXXXXXXX XXXXXXXX
+ + $
- $
Estimated for 12 Month Period Beginning
NonManufacturing Manufacturing
$
$
+
XXXXXXXX
+
XXXXXXXX
+
+
+
+
$
$
-
-
$
$
Page 4 of 5
Copyright, ISO Commercial Risk Services, Inc., 1994
CP 15 15 06 95 o
CALCULATION OF SPECIAL DEDUCTIONS ? MINING PROPERTIES
Royalties, unless specifically
included in coverage ...............................
$
$
Actual depletion, commonly known
as unit or cost depletion (not
percentage depletion)..............................
+
+
Welfare and retirement fund
charges based on tonnage.......................
+
+
Hired trucks .............................................
+
+
Enter this figure in Item I. on
previous page..........................................
$
$
CP 15 15 06 95
Copyright, ISO Commercial Risk Services, Inc., 1994
Page 5 of 5 o
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